One surgeon’s principles

I am in my 80s, and I know myself most fortunate to be able to make that statement. I have been a surgeon for nearly 50 years. I am grateful for those years of doing what I believe I was meant to do while enjoying almost every moment of that time. I am an academic who holds a dual appointment in surgery and biomedical engineering. In that role, I have attempted to be a mentor to residents in terms of surgical care, technique, and the attributes of practice that govern our discipline.

Over the years, based on my experience, I have formulated certain principles regarding the provision of care that have guided my career. I offer these 10 principles in the hope that they may be of interest to others.

It’s always your fault

Except for liability litigation, this precept is a good way to approach the acceptance of responsibility for the well-being and the life that a patient entrusts to you. Anticipate exigencies and attempt to prevent untoward events. Acknowledge bad decisions, even if they appeared to be the most rational choices when they were made. When assessing a bad outcome, recognize that there are no acts of God. I tell residents that if a patient falls out of bed, it’s their fault.

Postoperative complications can be solved intraoperatively

Carefully plan your contemplated procedure beforehand. Do every dissection, every anastomosis, and every operative step in your imagination before you enter the operating room. Intraoperative care and thought, careful technique, refusal to compromise for convenience, redoing a repair if in doubt, and constant reflection often will prevent the agonies of complications for your patient. Further, no matter how often I have done a particular procedure, before the patient is closed or the instruments removed, I replay the entire operation in my mind. If I am not satisfied with my mental video, I go back and try to remedy my concerns.

Gentleness, not speed, is the cardinal surgical virtue

Paraphrasing a surgical maxim from the 15th century, Harvey Cushing, MD, FACS, allegedly told aspiring surgeons: “The surgeon should have the eye of the eagle, the heart of the lion, and the hand of the woman.” Unfortunately, some surgeons have gotten these precepts confused and exhibit the “hand” of the lion or the eagle. Fortunately, we now have many outstanding women surgeons who quite naturally exhibit the hand of the woman. In Europe, speed is sometimes valued for its own sake. Continental surgeons often boast about how quickly they can do a procedure, as if they lived in the 19th century. However, in the age of advanced anesthesia and respiratory control, speed is a poor second to gentleness. Tissues are delicate; handle them carefully. Bleeding can almost always be avoided. Adhesions can be teased apart. The proper wrist posture when sewing with a curved needle will avoid suture cut marks. The finer the anastomotic suture material, the less likely a leak or stenosis will occur.

A learning curve can take time but should not take lives

It revolts me to hear surgeons boast of lowering their mortality rates during their learning curve. When a surgeon emerges from training, the surgeon should expect no mortality or significant morbidity because of a lack of skill. A learning curve should never be measured in patient mortality, but should rather be determined by time involved in performing a procedure and improvement in technical skills.

Venerate life

The employment of care conferences in intensive care units, wherein every person who has had contact with the patient— as well as an exogenous ethicist, in some cases—recommend life or death to a patient’s family has become ubiquitous. Reinhold Niebuhr, a 20th century American theologian, abhorred decision making by a committee and put his trust in the individual. For a surgical patient, that individual should be the surgeon. If the patient does not have untreatable cancer, dementia, or a terminal diagnosis, the surgeon should, in my opinion, be the advocate for life, even if limited, and not for death. Further, with respect to ageism in making surgical decisions, I have known a surgeon who in case discussions commonly expressed the opinion that attempting an operation or providing all-out care should be tempered and possibly not offered when the patient was more than 65 years old. I have always believed (even before I reached that age) that people older than age 65 deserve to live and should have any surgical procedure deemed necessary.

Be proud of your craft

I attended medical school on the East Coast, where, as a rule in those long-gone days, surgeons were considered dummies, the cast-offs of medical training. Many years later, I was invited to consider a job offer as chief of surgery at a prestigious northeastern university. I was told that the internists would work-up my patients and decide for or against a procedure; that the anesthesiologists would take care of them during and immediately after an operation; and that the internists, with the help of their specialists in cardiology, would then again take over their care. I asked, “What is left for me to do?” My escort was surprised by my question and responded, “You operate, of course.” In other words, the surgeon was still viewed by some as a technician. I have always denied that conception of our role. I believe the surgeon is an internist who can use his/her hands to follow through on what the mind dictates. In other words, competence in manual dexterity does not preclude cognitive ability.

Think creatively

Laboratory or clinical research leads to invention, and invention is the product of imagination. The imaginative process can be stunted by over-reading or over-analyzing at the beginning of the process. An idea should be dissected, contemplated, and relished by its originator before it is subjected to critical examination. After indulging the initial thought, however, it is time to explore the literature and re-examine the concept for originality and feasibility. If others have not previously and definitively conducted the experiment, or there are no strong data indicating that the concept cannot be made a reality, then it is time to plan the investigation and, if the search for funding is successful, to initiate the study. Thus, my research advice is this: think first, then read, then think again, but perhaps don’t read voluminously at first, for that may inhibit a good thought.

Be of service to the community

Sooner or later, we should emerge from the shelter of our working and personal time and engage in community activities, such as joining service organizations or initiating a novel contribution to society. In my case, I chose, together with Arthur J. Roberts, MD, FACS, a former cardiovascular surgeon and professional football quarterback, and with the endorsement of the National Football League (NFL) Players Association, to start the Living Heart Foundation-Heart, Obesity, Prevention & Education (LHF-HOPE) program. This activity screens former NFL players throughout the country for obesity, diabetes, heart disease, hypertension, and other ailments, and refers them for further diagnostics and therapy to a regional center of excellence. In phase two of the LHF-HOPE program, lectures are scheduled featuring former players who have reclaimed their good health. They speak on the hazards of obesity and other health care problems to professional organizations and industry groups. They also participate in public forums and presentations to the media. Since the public doesn’t typically pay a great deal of attention to suggestions by members of the medical profession and by most lay advisory groups, it is our hope that they might listen to some of the country’s most admired athletes—football players.

Know where we are in our professional time continuum

Surgery has moved from incisional (such as draining abscesses) to centuries of excisional procedures (primarily for cancer), to reparative cardiac, transplantation, and implantation operations. We maintain this heritage, but we must also move forward into the next phase of our discipline, namely, metabolic surgery. We are focusing on technology—laparoscopic, robotic, single orifice, natural orifice transluminal endoscopic surgery. But, no matter how beguiling technologic change is, we need to embrace the paradigm shift to metabolic surgery, which the late Richard L. Varco, MD, FACS, and I defined in 1978 as “the operative manipulation of a normal organ or organ system to achieve a biological result for a potential health gain.”*

There are myriad examples of metabolic surgery, starting with surgery for peptic ulcer disease, where surgeons operated on normal stomachs and vagal nerves without touching yet healed the pathologic lesion—the duodenal ulcer. Presently, metabolic surgery is best represented by bariatric surgery, where surgeons operate on the gastrointestinal tract to achieve a neurohormonal shift in metabolism in order to engender weight loss and ameliorate obesity comorbidities. The ultimate goal of metabolic surgery research is knowledge of the mechanisms and etiology of the diseases we treat (for example, diabetes).

Joy is in the process

Successful outcomes are satisfying and awards are gratifying, but the joy of surgery is in the process—the daily events of caring for patients, thinking about a new problem and thinking anew about an old one, the unpredictability and ever-changing novelty of events, and the physical pleasure of working with your hands.

The word “surgery” is derived from the Greek words “cheiros,” a hand, and “ergon,” work. In essence, we are defined as hand laborers. Thus, as surgeons we live a continuous adventure, are physically active, and literally able to shape events not only with our minds, but with our hands. It is only fitting that my 10 principles conclude with the fact that a surgeon will spend the majority of his or her life in the practice of this chosen vocation. Therefore, take joy in the process.

Note

This column is based on the graduation address that Dr. Buchwald delivered when he was accorded Honorary Fellowship in the Royal College of Surgeons of England in March 2014.